HomeMy WebLinkAboutFood Service Establishment Inspection 85 (14) i
Establishment: Yy Inspection Date: Time: ' REinsp
ddress/City: •h �,� Health Dept: &" Cl ;;-s 1 2
Based on an inspection this day,the items marked DNC identify the violations in operation or facilities which must be corrected by the date specified on page 2.
RISK FACTOR ITEMS: Listing is not inclusive of all possible debitable items C N/O N/A JDNC I KEY: C[complies] N/O[not observed] N/A[not applicable]
60 Qualified Food Operator 3 DNC[does not comply] 0[other] RTE[ready-to-eat]
61 Designated Alternate 2
12 .r Personnel with infection restricted C WO NIA 4
A Food workers have no exposed infected lesions/burns
62 Written documentatiop of training program 2 B Personnel with infection restricted
1 Approved source,wholesome,nanadulterated C N/0 NIA 4 C Communicable disease of worker reported to local health director
A I Approved shellfish,finfish,meat&poultry USDA approved 13 Handwashing facilities provided,hands washed,clean C 00 NIA 4
B Food cans in good condition(not dented,rusty,bloated,leaking) A Handwash facilities in all food prep/dispensing&warewash areas
C Wholesome/nonadulteratedfoods/safe B Handwash facilities in or immediately adjacent to toilet rooms
D Commercial products(no home grown/canned food) C Handwash facilities accessible/convenient to use
E Potentially hazardous foods received at proper temperature D Personnel hands washed,clean/Proper handwash procedure
O E Handwashing at appropriate times
3 Potentially hazardous food meets temperature requirements C No NIA 4 0
during storage,preparation,display,service and transports INon
15 Good hygienic practices C NIO NIA 2
A Hot holding greater than or equal to 140°F. (whole beef/pork roasts 130o F) A ❑ No eating ❑ No smoking while working
B Cold holding less than or equal to45°F. B Wounds covered adequately
C Proper cooling C Proper sink used for handwashing
D Proper re-heating 0
E Properinternalcooking/consumeradvisoryposted 4 anitization rinse(hot water chemical) C NIO WA
0 A Approved sanitizeravailable/adequate concentration ofsanitizer J.
4 Adequate facilities to maintain product C N/0 N/A 2 B Food-contact surfaces and utensils used for potentially
temperature,thermometers provided hazardous food sanitized at least every 4 hours
A Food thermometer available and accurate ol C Adequate ❑dishwasher sanitizer ❑final rinse temp
B Proper food thermometer for product L Proper sanitizing procedure
C Thermometers appropriately placed in cooler units E Sanitizing between raw animal origin&ready-to-eat food
0
0 25 Glean wiping cloths C N/0 N/A 1
7 Food protected during storage,preparation, C IWO WA
display,service and transportation A Cloths and/or sponges in good repair and clean
A Produce washed B Wiping cloths kept in sanitizer between uses
0
B Raw meats not stored/prepared near ready-to-eat foods 70
26 Food-contact surfaces clean C NIO NIA
C Food covered properly A Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards/sneeze guard B Single use gloves changed when soiled
E No unauthorized personnel C Food--contact surfaces clean
F No pooling of eggs not cooked immediately
8 Vood containers stored off the floor 30 Mot and cold water under pressure,provided as required Y NO NA 2
38 'Handwashing accessories provided C NI0 NIA
Handling of food minimized C N10 WA
A No unnecessary handling RTE and/or cooked foods with bare hands A Soap/paper towels/ drying device available
000,
B Dispenser(s)working: ❑Soap ❑Paper towel
B Minimize food handling,other than ready-to-eat,with bare hands C Handwash sink(s)clean/waste receptacle at handwash sink
C Adequate utensil(s)for dispensing food/ice 0
0 •DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS
The following information is not debitable and does not affect your score. KEY: QFO[qualified food operator],DA[designated alternate],PHF[potentially hazardous food],FS[foodborne]
PHFs are hot held at: OF. PHFs are cold held at: OF. Describe illness conditions when you would exclude a food worker from working:
Are internal cooking temperatures taken? Y N *To what temperature do you cook:
Poultry Ground Beef Pork What diseases related to FB illness are you required to report to the local health department?
Roasts Other
Describe re-heating procedures: Is there a written illness policy that requires the food worker to report specific illness conditions
Are temperatures recorded/logged for cold holding foods/equipment? Y N and diseases to the QFO? Y N *Do you have a paid sick leave policy? Y N
Are foods cooked in advance and cooled? Y N *Are leftovers saved? Y N Is there a language barrier between inspector&QFO? Y N ff-M indicate language spoken
List products cooled: by QFO/DA: *Can the QFO/DA read the inspection report? Y N
Describe cooling methods: Indicate who answered the above questions: Name(print):
Indicate the title of above person(circle all that apply):QFO DA Mgr Cook Owner FW
Is cooling monitored for time&temp? Y N Is the monitoring of cooling recorded? Y N .Obtain signature of the person who received the QFO responsibilities information at the time of the
[where:
there a produce washing policy? Y N *Describe what is washed and inspection:
Note: This report is a two page form(total of 62 debitable items) Page 1 of 2
Date of Fnspection:
dress Zhn LAL
Owner or Operator:
ADDITIONAL FOUR POINT ITEMS '
KEY: DNC [DOES NOT COMPLY]
6 Foods not re-served.
4 31 Sewage disposal approved.
-Unwrapped foods not re-served 4
-Potentially hazardous foods not re-served -Operating as required
No cross connections,back siphonage,backflow 11 Toxic chemicals. 4 Proper type/installation/backflow prevention device/air gap for: 4
-Stored properly,labeled properly,used properly -Food equipment -Hose connections -Dish machines
-Sanitizer concentration not to exceed maximum permitted -Soda system carbonator -Beverage dispensers -Toilet tanks
-No unnecessary toxics on the premises -Chemical dispensers -Ice machines
-Pesticides/rodenticides properly dispensed Proper drain for:
29 Water source adequate,safe. 4 -Food equipment -Dish machines -Ice machines
-Well/well head protected from contamination 35 Toilet facilities. Adequate,convenient,accessible, 4
-Water quality in compliance-Monitoring in compliance designed,properly installed
OTHER ITEMS KEY: DNC [DOES NOT COMPLY] o
2 Sources of food: Original container,properly labeled 1 arbage/rubbish storagearea/rooms,enclosures-properly constructed,clean
5 Potentially hazardous food properly thawed 2 Garbage/rubbish disposed of in an approved manner,at approved frequency
10 Food dispensing utensils properly stored 1 Atermin Control: No insects/rodents present
14 Food worker:Clean outer clothes,effective hair restraints 1 uteropenings protected againstentrance of insects/rodents
4 Floors: Floor covering installed,constructed as required,good repair,clean 1
16 Food-contact surfaces designed,constructed,maintained,installed, 2 45 Floors graded,drained as required
located
6 Floor,wall juncture covered
17 Nonfood-contact surfaces designed,constructed,maintained, 1 47 Mats removable,good repair,clean
installed,located
18 Single service articles,storage,dispensing 24aF xterior walking,driving surfaces,good repair,clean 1
19 No reuse of single service article 9 alls,ceilings attached,equipment properly constructed,good
repair,clean.Wall&ceiling surfaces as required
20 Dishwashing facilities approved design,adequately constructed, 2
maintained installed located 50 Dustless cleaning methods used,cleaning equipment properly stored 1
Equipment&Utensils; Cleanliness 1 51 Adequate lighting provided as required 1
21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors 1
22 Wash water clean,proper temperature 53 Rooms&equipment hoods,ducts,vented as required
23 Accurate thermometers provided,dish basket,if used 54 Rooms adequate,clean,adequate lockers provided,facilities clean L
27 Nonfood-contact surfaces of utensils&equipment clean 1
55 Establishment and premises free of litter,no insect/rodent harborage, 1
28 Equipment/utensils,storage,handling 1 no unnecessary articles
32 Proper disposal of waste water 1 56 Complete separation from living/sleeping quarters and laundry 1
33 Plumbing location,installation,maintenance 1 57 Clean/soiled linens stored properly 1;
36 Toilet rooms enclosed with self-closing door
58 No live birds,turtles,or other animals(except guide dogs) 1
1
37 Proper toilet fixtures provided,good repair,clean
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
3
entrance(s),smoking area indicated by sign(s)
39 Approved garbage/rubbish containers,adequate number,covered, 1
rodent proof,clean ❑Routine Inspection ❑Reinspection ❑ Preoperational Inspection
Other Inspection:
INSPECTOR: PERSON IN CHARGE: Demerit Score: *Include demerits from page 1
4 3 2 1 Total Rating
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prir t.Ll n me / /, print name v l C1 V
DATE CORRECTIONS DUE:
phone number title
-PAC'. 0 h Page 2 of 2 plus continuation pages Focused Inspection 1/2002
Page OI /
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLI^^SHMEN,Tn TOWN DATE OF INSPECTION
INSPECTION REMARKS
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INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INpSP�ECTION
INSPECTION FORM# REMARKS
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